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We explore the critical role of early intervention programs in supporting children with developmental delays. Pediatrician Maria Mba Wright shares insights into recognizing red flags like poor joint attention, navigating therapy options, and empowering families to access essential resources. Learn how early detection and comprehensive care can transform outcomes for children with autism and other developmental challenges.
Maria Mba Wright is a pediatrician.
She discusses the KevinMD article, “Gaps in the pediatric care of autistic children.”
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Transcript
Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Maria Mba Wright. She’s a pediatrician. Today’s KevinMD article is “Gaps in the Pediatric Care of Autistic Children.” Maria, welcome to the show.
Maria Mba Wright: Thank you so much for having me.
Kevin Pho: So let’s jump straight into this most recent article. Tell us what it’s about for those who didn’t get a chance to read it.
Maria Mba Wright: So really, it’s about almost tying in the pieces of the puzzle that are missing for us as pediatricians, as primary care providers, when it comes to the care of autistic children.
Kevin Pho: Perfect. So go into more detail. Tell us what you think are the missing pieces and the gaps of care when pediatricians care for autistic children.
Maria Mba Wright: Yeah, so just to give a little bit of background, I’ve been involved in primary care pediatrics for 17, almost 20 years, and so in the last couple of years, I changed roles and am now working on what you would call the other side—the place where pediatricians and primary care providers refer kids with developmental delays. And so by working in this space, I realized that there were crucial pieces of the puzzle missing that could make a difference. For example, understanding how the system works for these kids, the role of Early Start or Early Intervention that provides therapies for young kids, then what the school’s role, the insurance role, how they intersect.
The other key piece that I wish I would have known before is the concept of joint attention. Joint attention is the shared focus of two individuals on an object. This allows us to properly communicate, socialize, and learn. And when it comes to kids with autism, it’s missing in varying degrees. And so that’s something that I felt at the time—how can I impart this to my colleagues to make them aware?
Kevin Pho: So what would that look like in terms of that concept of joint attention for autistic children?
Maria Mba Wright: Yeah. So when you don’t have it, what you observe is that the child is not responding to his or her name, is not following directions, is in their own world, and eye contact is poor. And so as a result, what happens is the child prefers to play alone, doesn’t have the tools to socialize, the child isn’t speaking. And so parents will mention these things. And if you don’t, you’re not aware of this concept, you may not pay attention to it. But then the issue is they’re not talking, and they’re not talking because they don’t have this preverbal skill. It is developed as early as 12 months, fully developed by 18 months. And so these are things that are red flags that we can, if we know about it before 18 months, we can actually do something about it—refer.
Kevin Pho: And what are some of the reasons and barriers that prevent patients and their families from obtaining these types of interventions?
Maria Mba Wright: Well, one could be even us as primary physicians. We tend to say, “Oh, he’s young. We can wait. Let’s wait and see.” And so really, the parents come to us first. And so when we are not aware, when we think that maybe the child needs more time, then that becomes a barrier. And then, of course, the system—how the insurance system works—is another barrier. And the other last barrier, sorry, is the not knowing of the resources in our community that could be there to support these families.
Kevin Pho: So when it comes to that first barrier that you talked about—diagnosis—are you saying that some pediatricians are less aggressive or prefer to take a more wait-and-see approach versus others? Is there a standardized way of diagnosis, or is there more of a spectrum?
Maria Mba Wright: So there is a standardized way of diagnosis, and most of the time we start to offer screening tools at 18 months. And that is based on what we as pediatricians know. And what I found, going to being on the other side where we have to evaluate these children, is that knowing a little bit more about how these skills are achieved could help us not wait until 18 months or later. But yes, some of us pediatricians prefer to wait and see, “Oh, the child is young,” and actually, that’s not the right approach.
Kevin Pho: So for those who want intervention, you mentioned insurance as a barrier. Are these interventions not covered by some insurers? So let’s go back to the 0 to 3, Early Intervention, Early Start.
Maria Mba Wright: The good news, at least in California, is that you do not need to—it’s not, it’s covered for everyone, regardless of income. The issue is knowing about it. Right. And so for me, when I was working at a big HMO, I did not know what was offered. And I just kind of relied on what we had—just referred to get diagnosed. In the meantime, the child could be getting other interventions in the community. So that’s something I think is a part of just not knowing—the lack of knowledge and understanding is a big barrier.
Kevin Pho: Now, how about patients and their families? You said that some pediatricians take a wait-and-see approach. Should parents be more advocates for earlier intervention whenever they talk to their pediatrician who prefers a wait-and-see approach? What is the role of the parents in terms of pushing for appropriate intervention?
Maria Mba Wright: Well, I can tell you that they tend to be some of the best advocates, and sometimes in spite of what the parents—the pediatrician or primary care provider may say, they go ahead and ask and we get self-referrals, whether the parent is the one who actually contacted the Early Start program. I think though that if we are more involved and understand, we can help the families a little bit more because sometimes it’s the other way around. We see the problem, the parent does it. And so I think working together is just the best way.
Kevin Pho: So tell us the success story of early intervention where it moved the needle for that child’s autism.
Maria Mba Wright: So there was a child that came in, I would say, about maybe 18 months, to our Early Start program, having basically had speech delay, had some issues with attention, and we went ahead and started behavioral therapy. We started speech therapy, also occupational therapy to help with the sensory needs, because these are things that are needed. And so by the time they turned three—let me just go back—kind of go backwards. He was saying maybe two or three words and not really using them functionally, which is another issue. But by the time he turned three, he was able to ask for things, used two-word sentences, and was more interactive. So I think that is a success in a sense that we got him ready for school, and he was more receptive to learning because his joint attention skills had improved.
Kevin Pho: So you mentioned behavioral therapy. Take us into one of these sessions—what exactly does that look like? What are some of the techniques that they use to help children?
Maria Mba Wright: So the way behavioral therapy works, every child is different. As we know, autism is a spectrum. And so what is done first is an evaluation for the child in terms of where they’re at and their needs. And then a certain number of hours are assigned, and it could be up to 20, 25 hours a week. Most of the time, we start slowly and start building up from there because the child has some degree of tolerance. But the bottom line is, ideally, what should be happening is that the behavioral therapist works one-on-one with the child and the parents. For example, if the child is the type that runs away, elopes frequently, or has really bad tantrums, by doing the initial evaluation, you kind of figure out what they need and then slowly you start building the hours and you start redirecting the behavior. One of the things I do for myself at work is if I see that the attention skills are not there, I really emphasize that the therapist work on that joint attention because if there isn’t joint attention, guess what? The child isn’t going to absorb, so it can be up to 20, 25 hours, and they work on all the different needs that the child may have.
Kevin Pho: Now you mentioned those pediatricians who take more of a wait-and-see approach. What is some of the rationale behind those decisions?
Maria Mba Wright: I think that now, one of the things—and I’m just putting myself in their shoes—is, “Oh, maybe the child needs to mature a little bit. Maybe this isn’t this severe; they just need more time.” And I think that is an old way of thinking because when it comes to something like autism, the earlier we start the intervention, the better. What I explained to parents is kind of like an onion, and the more layers we wait and see, the more layers get added. And so then it becomes more difficult to penetrate those layers and change a behavior. It’s almost like us adults—as we get older, we get set in our ways. The younger we are, the plasticity is a lot easier. And so I think that it’s an old approach that we just need to change the way we think about things.
Kevin Pho: And in terms of early intervention, how successful are your outcomes?
Maria Mba Wright: So it depends—it varies because unfortunately, a lot of kids are referred late. We have kids that are referred at, say, 30 months, 35 months even. And so the success is really best based on the sooner they come in at 12 months, 15 months, and we get the right therapies involved, there is just a better chance. But there are a lot of moving parts, I have to say. And so, again, for me, changing that narrative makes a big difference. But what we’ll say in gross numbers, those who are referred sooner do better—they just do better.
Kevin Pho: So tell us what kind of things should parents be on the lookout for even before 18 months that may point to a potential diagnosis on the autism spectrum.
Maria Mba Wright: So if your child is not paying attention, is not making eye contact when you call their name, they’re not responding, they may appear sometimes to be in their own world, or they don’t want to play—they prefer to play alone. They won’t play with other kids when you all go out to the playground or the park. Those are red flags. And really, they start to notice, and it’s interesting how parents will express these observations as early as 12 months. And so I feel another thing is that we, as pediatricians or family practitioners, need to listen to our families. If they are saying this, that’s a problem.
Kevin Pho: So we’re talking to Maria Mba Wright. She’s a pediatrician. Today’s KevinMD article is “Gaps in the Pediatric Care of Autistic Children.” Maria, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Maria Mba Wright: Yes. So one is to become more acquainted with what resources are available in your community, the role of the school, Early Start, insurance, and how they intersect. Understand that to better take care of our children, our care isn’t just limited to the physical ailments. It’s really also what they’re receiving. And then the last thing is joint attention. This is the shared focus of two individuals on an object. It’s an important preverbal skill that we need for effective communication, effective learning, and effective socialization. And so this is lacking in varying degrees for kids with autism. And it shows as a lack of response when you call them, they’re in their own world, they’re playing alone, they don’t want to play with other kids. So the sooner we start to see these things, we need to refer because there is help available, and we can make a difference for these kids to thrive.
Kevin Pho: Maria, as always, thank you so much for sharing your perspective and insight, and thanks for coming back on the show.
Maria Mba Wright: Thank you so much. Thanks for having me.
